Treatment of panic disorder via the Internet: a randomized trial of CBT vs. applied relaxation
Introduction
As evidenced by several trials, cognitive-behavioral therapy (CBT) is a highly effective treatment for panic disorder (PD) (Taylor, 2000). However, only about 25% seek treatment (Lidren et al., 1994). The National Institute of Health (1991) postulated that barriers such as accessibility and affordability often prevented people suffering from PD from taking advantage of CBT. Lidren et al. (1994) suggested that bibliotherapy could be a way of overcoming these barriers.
In an attempt to provide a cost-effective treatment for these individuals, Carlbring, Westling, Ljungstrand, Ekselius, and Andersson (2001) developed an Internet-delivered self-help program and provided minimal therapist contact via e-mail. The program was recently evaluated in a randomized controlled trial which showed that the participants, compared to the waiting-list, achieved significant improvement in diary measurements of frequency of panic attacks, total intensity of each attack, total duration of each attack, and daily anxiety. Moreover, bodily sensations associated with the arousal accompanying anxiety were reduced, as well as anticipatory and catastrophic thoughts, agoraphobic avoidance, severity of anxiety symptoms, and depression. Finally, perceived life satisfaction was increased following treatment. With the exception of two dependent measurements, the treated participants reached a higher degree of clinical significant improvement compared to the waiting-list group. The results from this experiment generally provide evidence to support the continued use and development of self-help programs for PD distributed via the Internet. In addition, previous trials on other conditions suggest that the Internet can be used for administration of self-help treatments (e.g., Andersson, Strömgren, Ström, & Lyttkens, 2002; Lange, van den Ven, Schrieken, & Emmelkamp, 2001; Ström, Pettersson, & Andersson, 2001; Klein & Richards, 2000). A question that came up in our previous panic trail was if the time the therapist spent on each subject (approx. 90 min in total) could be reduced even more, and how important therapist monitoring of the patient's progress was. The present study deliberately minimized the time spent on each subject by using one of about 25 different standardized e-mail messages in response to questions. Furthermore, no time limit for the completion of the different treatment steps was set.
Instead of using a waiting-list control, which in an earlier study showed no improvement over time, a second treatment condition was employed. The choice of applied relaxation (AR; Öst, 1987) was made because it, at least in some studies, is equally effective as CBT (Öst & Westling, 1995). Furthermore, the delivery of this treatment is less demanding on the therapist and previous studies have shown that it can be delivered via the Internet (e.g. Ström et al., 2001; Andersson et al., 2002).
Section snippets
Recruitment and selection
Participants were recruited from a waiting-list of people who had expressed an interest in taking part of the Internet-administrated self-help program for PD. Originally they were recruited by means of newspaper articles in national and regional papers, notices in health magazines, and by an Internet link from the home page of the Swedish National Association for people suffering from PD. Mean time on the waiting list was 15 months.
A home page was created for the study, which included general
Results
The two groups did not differ significantly in any of the measurements at pre-treatment. Results will be presented in the following order: self-report inventories, panic diary recordings, effect size, treatment credibility, and, finally, the questionnaire assessing participants’ responses to the program.
Discussion
The results from the present study suggest that Internet-administered self-help plus minimal therapist contact via e-mail has an overall medium to large effect. Although not statistically significant, the AR condition has a better overall effect compared to the CBT program (d=0.71 and 0.42, respectively). However, as no time-effect condition was included in the study the equivalence of the two treatments could indicate similar effectiveness or similar ineffectiveness. Although unlikely, all
Acknowledgments
This study was sponsored by grants from the Swedish Foundation for Health Care Sciences and Allergy Research, the Boëthius Foundation, the Swedish Council for Research in the Humanities and Social Sciences, and the Söderström-Köniska Foundation. We thank Per Forslin and Carola Strandlund for the SCID-interviews.
References (28)
- et al.
Credibility of analogue therapy rationales
Journal of Behavior Therapy and Experimental Psychiatry
(1972) - et al.
Treatment of panic disorder via the InternetA randomized trial of a self-help program
Behavior Therapy
(2001) - et al.
The mobility inventory for agoraphobia
Behaviour Research and Therapy
(1985) - et al.
Interapy. Treatment of posttraumatic stress through the InternetA controlled trial
Journal of Behavior Therapy and Experimental Psychiatry
(2001) Applied relaxationDescription of a coping technique and review of controlled studies
Behaviour Research and Therapy
(1987)- et al.
Applied relaxation vs. cognitive behavior therapy in the treatment of panic disorder
Behaviour Research and Therapy
(1995) - et al.
The effects of cognitive-behavior therapy for panic disorder on comorbid conditions
Journal of Anxiety Disorders
(1998) - American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington,...
- Andersson, G., Lundström, P., & Ström, L. (2003). Internet-based treatment of headache. Does telephone contact add...
- et al.
Randomised controlled trial of internet based cognitive behavior therapy for distress associated with tinnitus
Psychosomatic Medicine
(2002)
An inventory for measuring clinical anxietyPsychometric properties
Journal of Consulting and Clinical Psychology
An inventory for measuring depression
Archives of General Psychiatry
Assessment of fear of fear in agoraphobicsThe body sensations questionnaire and the agoraphobic cognitions questionnaire
Journal of Consulting and Clinical Psychology
Coping with panic
Cited by (160)
Nowhere else to go: Help seeking online and maladaptive decisional styles
2022, Computers in Human BehaviorApplied Relaxation
2022, Comprehensive Clinical Psychology, Second EditionRemote cognitive behavioral therapy for panic disorder: A meta-analysis
2021, Journal of Anxiety DisordersDisorder-specific internet-based cognitive-behavioral therapy in treating panic disorder, comorbid symptoms and improving quality of life: A meta-analytic evaluation of randomized controlled trials
2021, Internet InterventionsCitation Excerpt :In the 13 RCTs (N = 1214), we investigated a total of 19 comparisons that were eligible for the final analysis. We included comparisons where Gsh iCBT was compared to a) fCBT (⁎Bergström et al., 2010; ⁎Carlbring et al., 2005; ⁎Kiropoulos et al., 2008); b) applied relaxation (⁎Carlbring et al., 2003); c) Gsh iCBT with frequent contact to an online therapist (⁎Klein et al., 2009), Gsh as a manualized workbook (⁎Klein et al., 2006) and Gsh + stress management course (⁎Richards et al., 2006); d) self-help iCBT (⁎Ciuca et al., 2018; ⁎Fogliati et al., 2016; Andersson et al., 2009) and transdiagnostic self-help iCBT (⁎Fogliati et al., 2016), e) WL (⁎Allen et al., 2016; ⁎Carlbring et al., 2001; ⁎Carlbring et al., 2006; ⁎Ciuca et al., 2018; Andersson et al., 2009; ⁎Wims et al., 2010); f) IC (⁎Klein et al., 2006; Andersson et al., 2009; ⁎Klein et al., 2006; Andersson et al., 2014; ⁎Richards et al., 2006; Andersson et al., 2009); and g) self-help iCBT compared to WL (⁎Ciuca et al., 2018; Andersson et al., 2014). Regarding the study from ⁎Allen et al. (2016), we used only the first from two studies, as the second study was an open trial.
Are Internet- and mobile-based interventions effective in adults with diagnosed panic disorder and/or agoraphobia? A systematic review and meta-analysis
2020, Journal of Affective DisordersCitation Excerpt :Pre-post effect sizes for panic symptom severity ranged between g = −2.85 (iCBT with stress management modules and therapist contact) and −1.03 (iCBT with infrequent support). CIs indicated significant reductions for all interventions, except for the intervention investigated by Carlbring et al. (2003) yielding a within group effect size of g = −0.76 (p = .0892). Pre-follow-up results indicated significant effect sizes, ranging from g = −3.49 to −1.03.